Instructions For U-1201 - Request For Visit (Rfv) Form Page 3

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UNCLASSIFIED
REQUEST FOR VISIT CONTINUATION
VISIT ID NO:
____________________________
10. THE SECURITY OFFICER OF THE REQUESTING GOVERNMENT AGENCY OR INDUSTRIAL FACILITY
(MUST BE SIGNED BY A SECURITY OFFICER OR FSO, OTHERWISE THE FORM IS INVALID)
NAME:
______________________________________________
SIGNATURE:
_____________________________________________
TELEPHONE NO:
______________________
FAX NO:
________________________
11. CERTIFICATION OF SECURITY CLEARANCE
NAME:
Defense Security Service, Industrial Policy & Programs, International Division
27130 Telegraph Rd
ADDRESS:
Quantico, VA 22134
Email: iab@dss.mil
TELEPHONE NO:
855-834-0375 Fax: 571-305-6010
12. REQUESTING NATIONAL SECURITY AUTHORITY
NAME:
Defense Security Service, Industrial Policy & Programs, International Division
ADDRESS:
27130 Telegraph Rd
Quantico, VA 22134
Email: iab@dss.mil
TELEPHONE NO:
855-834-0375 Fax: 571-305-6010
13. REMARKS
FORM U-1201
NOV 2014

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